Auditing Issues Uncovered in Physician Documentation: Part II

Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI.

Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor.

As I discussed in the first portion of our series on physician documentation issues during an audit, errors can occur on both sides, physician documentation and coding – even with proactive clinical documentation improvement (CDI) departments correcting negative behaviors and coders trying to educate physicians and mid-level providers on what is needed to support a particular level of service.

But it is an ongoing process. Physicians and physician-extenders alike get busy and overwhelmed treating patients, with their ever-increasing volumes, and even with the assistance of the electronic health record (EHR), deficiencies will happen. Some of the good documentation and coding behavior upon which physicians were educated and trained on tends to fall by the wayside over time. In my experience, there is marked improvement within the first three to six months after training sessions, and then a decline in accurate documentation starts to show. Many records start to feel like they were rushed, or only slightly edited, and not actually taken during the patient encounter.

If you look at the history component of an evaluation and management (E&M) encounter, this element is where the medical necessity begins. It can lay the groundwork for the physician’s “right” to move forward with the exam and medical decision-making. Without a well-documented patient history, it would be hard to justify moving forward with an extensively documented record; there would be no basis for it.

In a Centers for Medicare & Medicaid Services (CMS) call on March 21 regarding potential changes to E&M documentation guidelines, I heard many physicians of different specialties trying to make an argument that the history component of a medical record should be eliminated. This made no sense, as the history can be the most important aspect of a medical record. Both the 1995 and the 1997 American Medical Association (AMA) CPT® Documentation Guidelines require a “chief complaint.” A chief complaint is the reason a patient needs to meet with the physician. If there is no chief complaint, or no acute or chronic condition, the patient is being seen for what may be considered preventative reasons.

A chief complaint is a statement, typically in the patient’s own words: “my knee hurts,” for example, or “I have chest pain.” On occasion, the reason for the visit is follow-up, but if the record only states “patient here for follow-up,” this is an incomplete chief complaint, and the auditor may not even continue with the record and negate its value altogether. It is imperative for the provider to be specific in their documentation on the condition being followed up on, i.e. “patient here for follow-up for their sprained knee” or “patient here for follow-up of their hypertension.”

If the chief complaint is a chronic condition, which is also an allowable chief complaint entry, one word that is in every audit tool with regard to coding and documenting such a condition is “status.” I have found that most physicians who forego the sign or symptom complaint for three chronic conditions tend to forget that it must include the “status of the condition” or it does not count as a chief complaint.

So for example, if your physician is going to document “hypertension, diabetes, and high cholesterol” as the chief complaint, this is not sufficient for three chronic conditions. The more appropriate documentation would be:

Chief complaint:

  • Hypertension, compared to last visit, is well-controlled with ACE inhibitors and diet modifications.
  • Type 1 diabetes, insulin dependent, without complications, and has been better about managing his sugars.
  • Hyperlipidemia controlled with Lipitor and some mild diet and exercise changes.

When the physician can document this kind of detail in the record, the auditor will have a better understanding of the total health picture of the patient, without having to search out the entire record, and can just focus on the encounter.

When the chief complaint is a sign or symptom communicated by the patient, the physician, based on the documentation guidelines, is supposed to ask questions to get a complete description and chronological account of the problem to be treated. According to CMS, the history of present illness (HPI) must be documented by the physician, and cannot be documented by the ancillary staff.

As an auditor, I see this being documented by the medical assistant often, and that is not appropriate. These timeline questions that the physician goes through may prompt a further discussion of the problem and/or uncover a potential underlying cause or condition that only a physician’s expertise can extrapolate. Ancillary staff can take vitals and enter the review of systems (ROS) information sheet into the medical record. But the HPI is the physician’s responsibility, and these elements need to be understood.

The description of the HPI is in both the 1995 and 1997 guidelines. There are eight HPI components:

  1. Location: The anatomical place, position, or site of the CC (back pain, sore neck, cut on leg, etc.)
  2. Quality: A problem’s characteristics, such as how it looks or feels (yellow discharge, radiating pain, burning urination, etc.)
  3. Severity: A degree or measurement of how bad it is (improved, unbearable pain, 7 on a scale of 1-10, etc.)
  4. Duration: How long the complaint has been occurring, or when it first occurred (since childhood, first noticed it a week ago)
  5. Timing: A measurement of when or at what frequency the patient notices the problem (intermittent, constant, only in the evening, etc.)
  6. Context: What the patient was doing, environmental factors, and/or circumstances surrounding the complaint (while standing, during exercise, after a fall, etc.)
  7. Modifying factors: Anything that makes the problem better or worse (improves with aspirin, worse when sitting, better when lying down, ice seems to help, etc.) If medication is documented as a modifying factor, it should also be noted the result of using the medication (Tylenol reduces the pain).
  8. Associated signs and symptoms: Additional complaints that may be related to the chief complaint (chest pain with occasional shortness of breath).

The number of components documented for the HPI will determine the HPI level at either brief or extended.

Below is an example of how an auditor would “grade” or score a physician in his or her HPI, based on a documented chief complaint.


HPI Level Elements Required Example
Brief One to three HPI elements Patient is here for knee (location) pain lasting two weeks (duration)
Extended Four or more HPI Elements Patient is here for intermittent (timing) knee (location) pain lasting two weeks (duration). She states it is a dull ache (quality) type pain that increases when she runs (modifying factor).


This is to illustrate how leaving out important elements of documentation could change the level of service and result in lost revenue if you are not accurate. This discussion is not to encourage added elements to increase the E&M level of service, but to enlighten providers that leaving out components from the history portion of the encounter, or not taking the time to be efficient in their documentation, can lead to failing an audit, inaccurate scores on audits, and lowered reimbursements.

Our plan in the third part of this four-part series is to tackle the review of systems (ROS) portion of the history, and past, family, and social history (PFSH). These elements can also have an impact on ICD-10-CM choices, as well as the leveling of services.

Auditors are bound by the documentation rules, and physicians need to be aware that those rules are for the protection of the patient in the completeness of the record – but also to assist the physician as a prompt during the encounter with the patient.

No one wants to miss out on information that may be directly or indirectly related to the encounter and could support medical necessity.

Program Note:

Listen to Terry Fletcher report on the second piece of her four-part series today on Talk Ten Tuesdays, 10 a.m. EST.


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